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Based on observation, record review and interview, the facility failed to provide a safe environment for 1 of 3 patients diagnosed with a severe form of a mental health issue. (Patient #1).

Findings:

Observation of Patient #1 on 10/26/17 beginning at approximately 8:30 AM included several attempts to speak with the patient but she refused both verbally or physically turning away. During the lengthy observation until approximately 9:30 AM, she was observed with no clothes on. She agreed to wear a blanket around her body as she sat in the day room. She has just come from her bedroom with no clothes, into the hall and nurse's station. She periodically goes to the lexan glass nurse's station and pounds on it with her fist. She screams for different items such as coffee and pain medications. At other times, while she was speaking English, it was not clear what she wanted. She had no statements of abuse or neglect. She was observed to sit in the day room and speak, but to no one. It was not clear what she was actually saying. At times she would scream out curse words but not directed to anyone or a specific situation. She refused all attempts by staff to determine what she might want or was saying. She did not repeat any of the utterances. She was observed to be physically capable with independent mobile/ambulatory movement throughout the facility. She was alert and oriented to her room and the nurse's station. She was able to move to the day room with ease and quickness. She engaged with no staff and no other patients. She did not shy away from anyone. She had no marks, but her appearance was unkempt with messy hair.

An observation of the video tape for Hall 400 where Patients #1 & #2 lived on 10/21/17 revealed all but 2 patients were not in the day room or hallway at 2:19 PM. Patient #2 was visible wandering through the hall and day room. He went down the hall turning each patient's bedroom door, which were locked. Patient #2 was in her room so her door was unlocked. Patient #1 disappeared into Patient #2's doorway. There is no movement in the hall, then at 2:30 PM, the charge nurse comes into the hall and is moving quickly looking at each door then goes into Patient #1's room, comes out of the room , almost immediately, with Patient #2. No further coverage revealed any issues.

During an interview with a Registered Nurse (Charge Nurse on 10/21/17) on 10/26/17 at approximately 9:50 AM, she stated she was working on 10/21/17 and found Patient #2 behind the door in Patient #1's bedroom. She stated she heard Patient #1 scream and she went to her room. She stated Patient #2 had taken off his hospital gown and was "behind the door with a white substance which looked like ejaculate on his hands." She stated he denied any penetration. She stated she immediately took him out of the room, after he quickly put his hospital gown back on and reported to her supervisor. They called law enforcement, commenced an investigation, then removed Patient #2 from the facility. She stated she asked administrative staff earlier in the morning why Patient #2 was not on 1:1 supervision. She stated concerns were voiced to her from the floor staff when they arrived for their shift that morning about Patient #2. She stated the administrative staff stated they had not received any negative reports about Patient #2. She confirmed she had not been given any special directives for Patient #2 nor updated on his recent history in the facility from anyone but the MHTs. She confirmed the intake assessment did not include any of the recent sexually aggressive behaviors noted in his visit 2 weeks earlier. She stated Patient #2 arrived on the floor about 12:35 PM on 10/21/17 and left at 2:30 PM.

During an interview with Mental Health Technician A on 10/26/17 at approximately 9:45 AM, he stated he was "very surprised they took him back," referring to Patient #2. He stated he did not work on 10/21/17, but he was aware Patient #2 was found in Patient #1's room behind the door with his hospital gown off. He stated the charge nurse had heard Patient #1 scream out loud. He sated she said she went to her room and found Patient #1 laying on her bed with Patient #2 hiding behind her door. He stated Patient #2 was removed by law enforcement within a short period of time. He stated Patient #2 had just been discharged from the facility about 2 weeks earlier. He said on 10/8/17-10/9/17, he had been assigned to act "kind of as a one on one, watching him all the time, because he had already touched people inappropriately, both patients and staff, including a therapist." He stated they had tried to work with him and redirect him but he continued on in the sexual aggressions constantly. He stated they could not leave him unattended at all.

During an interview with Mental Health Technician C on 10/26/17 at approximately 1:00 PM he stated he had been suspended pending the outcome of the investigation regarding Patient #2. He stated he heard the investigation was almost complete and he expected to hear today. He stated on 10/21/17, Patient #2 was placed on the 400 hall where he was assigned for the shift at about 12:45 PM. He stated his coworker MHT D had taken 7 patients outside on the patio. He stated he was inside with Patients #1 & #2. He stated Patient #1 was sleeping in her room which is what she usually did every day. He stated Patient #2 was watching television in the day room in front of the nurse's station. He stated he went to the bathroom and was only gone for 5 minutes. He stated the charge nurse was supposed to watch the patients while he was gone. He stated that was when Patient #1 screamed and the charge nurse went to her room and found Patient #2 hiding behind her door. He denied anyone giving him special instructions for Patient #2. He said he was punished for not dividing the patients in an equitable manner with his coworker. He said they worked as a team which they should not have done.

During an interview with Mental Health Technician D on 10/26/17 at approximately 1:30 PM she stated she had been fired yesterday. She stated she was placed on suspension pending the outcome of an investigation, after Patient #2 had been found in Patient #1's room behind the door. She stated she was fired because she and MHT C were working together in supervising the patients and he was supposed to put the checks on the Q 15 supervision form for the patients and he did not. She stated she was outside and had no knowledge of the incident until it was over. She confirmed Patient #1 refused to cooperate with examinations and the investigations.

Review of Patient #1's chart revealed a nurse's note, dated 10/21/17, which stated "Patient reports sexual assault by another male resident. House Supervisor notified along with Risk Manager. LEO notified. ARNP notified & examined client with orders to send out to ER for Eval. Family notified by House Supervisor. ......Refused to cooperate with detective in obtaining gown for evidence. Gown finally obtained with her cooperation & detective took possession. .... Doctor called. Patient complied with medications by mouth.... Male client removed from 400 hall." A Follow up History and Physical by the Registered Nurse Practitioner on 10/21/17 at 5:30 PM states "Chief complaint is confusion, history of sexual contact. It is reported an intruder went to patient's home and the intruder was masturbating. The patient is confused, unable to explain what happened. The intruder is also confused due to schizophrenia. For precaution measure, we will send the patient to the Emergency Room for Gynecologic Evaluation." The first Physician's order at 5:30 PM notes "Send to hospital for Gynecological evaluation. Please evaluate for penetration confusion." The Physician's Order form notes on 10/21/17 "ok for crisis nurse to examine pt & obtain needed specimens." Physician's note on 10/24/17 "verbally aggressive, exhibiting paranoid delusions, when tried to talk to her about recent traumatic incidents, she refused to participate and left the room." On 10/22/17, the night shift nurse's notes states, "she informed nurse, she would like to see crisis nurse but then refused to sign form and then refused the assessment. " The Nurse's/Physician's notes between 10/19/17 and 10/25/17, completed daily, revealed the patient was "psychotic," found "naked" repeatedly in her room or in the hall, "cursing," yelling profanities, kicking at staff and cursing at staff and no one in particular. The Intake and Nursing Assessments state she is "unable to assess," she refuses or is unable to answer the questions "due to her psychosis." Patient #1's Psychiatric Evaluation dated 10/18/17, states she was admitted under a Baker Act through the Sheriff's Department with complaints she was walking around the neighborhood with knives in her hand and making irrational statements. "Patient is a very poor historian and was not able to provide any information." Patient was combative with officers during the course of the Baker Act. "She has a history of being hospitalized in a State Psychiatric facility, from where she was recently discharged." The Admitting Physician's Form states on 10/19/17, the diagnosis is Bipolar, Manic with Psychotic features and chronic lower back pain. Under Precaution Level it notes "sexual victimization" and "aggressive behavior/assault." The Diagnostic Form dated 10/21/17 notes Schizoaffective Disorder, Bipolar Type.

Review of Patient #2's record revealed the patient refused to sign most of his Involuntary Admittance and Resident Rights forms. The Certificate of Involuntary Examination signed by a Physician on 10/20/17 states "found by police walking barefoot trying to grab people, turned violent on initial contact." His diagnosis is listed as Paranoid Schizophrenia. It stated "Mother states he is not taking meds, she cannot control him, and is afraid of him-as he turns violent quickly." His Risk Factors Noted on 10/21/17, at 11:45 AM, noted Suicide, Violent, Psychotic/Confused, Sexually Acting Out Precautions with Perpetrator checked. While it was checked the Physician was notified of these risks on 10/21/17 at 11:45 AM, there were no signatures or dates and times from the author (Intake Nurse) or the Physician. The Assessment completed by the Intake Nurse on 10/21/17 at 12:00 PM, states Patient #2 asked her "for a hug then said rape me." The Nurse writes she called his mother and she said "he has been psychotic for 2 weeks." He has been "going into the streets, disrobing & touching people inappropriately and that he has threatened her." Under the Past Treatment History section, the question "has patient been admitted to TVH (The Vines Hospital) within the past 30 days, the Intake Nurse answered "No." She wrote he "disrobes, aggressive at hospital with restraints". She writes "unable to articulate" to most of the questions on the assessment. At the Additional Information section at the end she wrote "Dr present at the adm & wrote ETO, pt taken directly to unit, as he is unable to participate in interview, aggressive and sexually inappropriate." The Intake Nurse signed the Intake Assessment at 11:45 AM on 10/21/17.

Further review of Patient #2's record revealed a second chart dated 10/8/17-10/9/17. On 10/9/17, between 9:15 AM and 11:30 AM, the Day Shift Nurse's Note states "pt making sexually inappropriate comments towards MHT and nursing staff, grabbed therapist by the arm and began licking his lips. Doctor notified. Evaluation with Medical Director and pt identified for DC. Pt came out of his room and slapped a female peer in the "butt," while walking down the hall." On 10/9/17 at 11:55 AM, the Recreation Therapist wrote in the Progress Note, "did not attend due to cognition, he was very hypersexual." On 10/8/17, the Intake Nurse checked under the Risk Factors on the Intake Assessment, "Suicide Ideation, Homicide Ideation, Violent, Psychotic." Both the Intake Nurse and the Physician Signed and dated the form on 10/8/17 at 3:50 PM. This information was not provided to the Physician or Nursing staff on 10/21/17.

During an interview with Patient #1's Therapist on 10/26/17 at approximately 9:30 AM, he stated the patient had arrived at the facility under Baker Act on 10/18/17 but had refused any contact with him till 10/25/17. He stated she came into his office which is across from her bedroom without cueing. He stated she was very calm but there was little/no information from her . He stated she left the room on a pleasant note. He noted she made a rude gesture in his office window later on in the day. He stated she stays in her room every day, coming out to yell, curse or physically aggress toward the building or staff. He stated she has made no communication with anyone about any allegations of abuse/neglect to his knowledge. He stated he has not noted any change in her behavior during her stay here. He stated he did not work over the weekend and had no information about the incident. He denied working with Patient #2.

During an interview with the Admissions Director on 10/26/17 at approximately 12:30 PM she confirmed the Intake Nurse met the minimum criteria of completing the Intake form, but she did not provide any information of the previous sexually aggressive behaviors exhibited in the facility, only 2 weeks earlier, by Patient #2. She did not provide any policies the facility might have for admitting patients known to have high risk behaviors. There was no response to the issue regarding the inaccurate information the Intake Nurse made under "Treatment History section, the question "has patient been admitted to TVH within the past 30 days, the Intake Nurse answered "No."

During an interview with the Chief Nursing Officer (CNO) on 10/26/17 at approximately 10:00 AM, she confirmed Patient #2 had been found behind the door in Patient #1's room. She stated she had been updated about the investigation throughout the week. She confirmed 2 of her MHTs were on suspension pending the outcome of the investigation. She confirmed and provided documentation she was already retraining all of the floor staff regarding supervision on the halls. She confirmed the admission staff 's assessment for Patient #2 was sparse and did not include pertinent behavioral information that was necessary to provide a safe environment. She confirmed the statement, on the Admission Assessment written by the Intake Registered Nurse about her discussion of Patient #2's risks, was a broad and generalized statement. It did not clearly state exactly what the Intake Nurse and the doctor discussed. She confirmed a significant portion of the assessment was not completed due to the patient's lack of cooperation. She confirmed there was no mention of his behavioral risks from his stay at this facility 2 weeks earlier. She confirmed Patient #2's discharge from this facility on 10/9/17, after only 1 day in the facility, was due to his lack of cooperation with the program, for his behavioral issues.

During an interview with the Director of Performance Improvement (DPI) on 10/26/17 at approximately 8:15 AM she stated she was in meetings this week with the Risk Manager and the Chief Nursing Officer (CNO) as they discussed an investigation the facility had initiated regarding the circumstances reported on 10/21/17 at 2:30 PM by the Charge Nurse on the 400 Hall. She stated the Risk Manager investigated the allegation but was not in the building on this date. She stated the 2 Mental Health Technicians A & B assigned to the 400 hall at that time had been suspended on that day, pending the outcome of the investigation. She stated Patient #1 suffered from psychosis and had been uncooperative with treatment since she arrived in the facility. She stated Patient #1 had refused an examination after the incident. She stated she could provide no written information regarding the investigation due to company procedures. She confirmed while the Intake Nurse met the minimum criteria of completing the Intake form, she did not provide any information of the previous sexually aggressive behaviors exhibited in the facility, only 2 weeks earlier, by Patient #2. There was no response to the issue regarding the inaccurate information the Intake Nurse made under "Treatment History section, the question "has patient been admitted to TVH within the past 30 days, the Intake Nurse answered "No."

During an interview with the Psychiatrist on 10/26/17 at approximately 1:30 PM, she stated she was a new employee and had no knowledge of Patient #2's recent stay in this facility. She stated she was not provided any of the information regarding his sexually aggressive behaviors and refusal to cooperate with the program during his stay. She confirmed the Intake Nurse met the minimum criteria of completing the Intake form, but she did not provide any information of the previous sexually aggressive behaviors exhibited in the facility, only 2 weeks earlier, by Patient #2. She stated repeatedly she had no hesitation in placing any patient on 1:1 supervision when they engage in sexually aggressive behavior. She stated she ordered the 400 hall for Patient #2 which has lower patient/staff ratios than the other 2 halls, because of the circumstances of his Baker Act, which included the sexually aggressive behaviors.




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